In Reply: The Pennsylvania state hospital system has achieved a culture change that rejects the use of seclusion and restraint. We believe that these traumatizing procedures produce significant barriers to a recovery and have no clinical value. The total elimination of these interventions is a clinical reality for Pennsylvania state hospitals and for many psychiatric facilities worldwide. As of this date, six of our eight state hospitals have eliminated the use of seclusion and two hospitals have eliminated the use of mechanical restraint.
Our reliance on these interventions continues to decrease. In January 2006, during which 67,000 days of care were rendered in the civil and forensic services, seclusion was used only two times for a total of 75 minutes, and mechanical restraint was used only seven times for a total of 7.83 hours. This decrease represents a 99.9 percent reduction from the 1996 rate. The transformation occurred without increases in hospital staffing. From 1996 to 2006 the patient-to-staff ratio has remained constant, with an on-unit ratio of one nursing worker for every five patients on the first and second shifts.
The "enormous transinstitutionalization" referred to by Dr. Liberman has not been a significant issue for Pennsylvania, which, like other states, provides services to an increasing number of people who have had contact with the criminal justice system. Our approach to service is the same for this group. Indeed, use of seclusion and restraint in our hospitals' forensic centers has historically been much less than in the general (civil) psychiatric service units.
In our article we did express concern about use of unscheduled (PRN) medications as a possible substitute for the hands-on use of restrictive procedures. After publication of findings by Thapa and colleagues (1) of exposure of patients to unnecessary psychotropic medications, our hospital system conducted a 15-month study of the psychiatric use of PRN medications in its nine civil hospitals and three forensic centers. The effort showed widespread differences within the hospitals and forensic centers in exposure rates. The findings led to a uniform policy change that discontinued the psychiatric use of PRN orders in the hospital system in March 2005. Since this change, we have seen marked improvements in our patient safety measures, including further decreases in the use of seclusion and restraint, incidents of aggression, and patient-to-patient assaults with injury (2).
The work of the APA task force on seclusion and restraint cited by Dr. Liberman still represents a good start for any psychiatric facility or clinician wishing to engage in this change. We also recommend the work of the National Technical Assistance Center of the National Association of Mental Health Program Directors: (www.nasmhpd.org/ntac.cfm).
Finally, we welcome this kind of exchange and scrutiny. Pennsylvania's state hospital system has been transparent in its efforts to share its experiences. Each month we distribute data to several states in the form of a summary report that details incident data. Interested readers who desire more information or data should contact the first author (firstname.lastname@example.org).
1.Thapa PB, Palmer SL, Owen RR, et al: PRN (as-needed) orders and exposure of psychiatric inpatients to unnecessary psychotropic medications. Psychiatric Services 54:1282-1286, 20032.Smith GM, Davis RH, Altenor A, et al: Psychiatric use of unscheduled medications in a state hospital system. Presented at the American Psychiatric Association's Institute on Psychiatric Services, San Diego, Oct 5-9, 2005